Drug promotion, problems, policy​

This past spring, I posed this question with the intention of drawing upon six indicators found in the literature. Along the way, a few other indicators appeared in support of the six, but the central thrust has revolved around the following six indicators which warrant just a brief review.

Cost to the Economy: includes a wide variety of data on health care, social costs, enforcement, and productivity

Drug Use: acknowledging that mere use of a drug is a potentially challengeable proxy for actual drug problems

Risk Behaviour: not actual harm from drug use, but behavior that increases one’s risk of experiencing harm - an example being impaired driving

Actual Harm: demonstrated harm to one’s physical, mental, or social functioning

Dependence: meeting standardized criteria that demonstrate dependence on a drug

Mortality: drug-related deaths.

So, what would be our dashboard depicting the worst drug problem? It depends upon how we might choose to slice and dice the indicators. Going with all six individual indicators, we get the following view:

Cost to the Economy            tobacco

Drug Use                                alcohol

Risk Behaviour                      alcohol

Actual Harm                           alcohol

Dependence                          alcohol & tobacco

Mortality                                  tobacco

Our observation would be that alcohol leads on three indicators, tobacco on two, with one tie, so alcohol emerges as the worst drug problem.

Another dashboard view would collapse the micro indicators (drug use, risk behavior, actual harm, dependence) into one category called morbidity.  This would yield:

Morbidity:                               alcohol

Mortality:                                 tobacco

Cost to the Economy:           tobacco

Our conclusion, from this view, would be that tobacco is the worst drug problem.

I think we could feel justified supporting either view. Personally, I would lean a bit towards the latter dashboard with tobacco as Ontario’s worst drug problem. I’m sure others would argue for alcohol, and I would not be inclined to challenge them. While a contest provides an engaging writing device, it really doesn’t have to be a contest where alcohol and tobacco are concerned.  Informed knowledge brokers are content to conclude that alcohol and tobacco are our two worst drug problems. That conclusion is unchallengeable.  A focus on alcohol and tobacco provides a convenient segue to the next important question: Why are alcohol and tobacco our two worst drug problems? And that also provides segue to the next series of posts in Drug Promotion, Problems, Policy. In a new series, we will explore this question from a variety of perspectives, drawing upon data related to themes already introduced in DPPP:

• drug industries and drug promotion as vectors of drug-related harm
• the importance of supply-side prevention
• drug policy success and failure

I would like to acknowledge the ongoing support for DPPP by Portico, EENet, and HPRC, and also the interest of the readers and discussants. I look forward to your lively participation in the next series: Alcohol and Tobacco Advertising: What’s Wrong with This Picture?

How often have we witnessed an overly-maudlin proclamation of “Drugs kill”? We envision a wild-eyed war on drugs crusader calling for tougher action, oblivious to the much-needed demise of that devastating and sorry excuse for drug policy. We roll our eyes and change the channel, close the book, click on close, or stop listening. Interestingly, the reality is that drugs do kill people – lots of them. The Canadian Centre on Substance Abuse’s Report, The Cost of Substance Abuse in Canada showed that, in Ontario alone, the toll for alcohol, tobacco, and illegal drugs comes in at about 80,000 deaths per year. The corresponding figure for Canada is about 220,000. These estimates do not include deaths from pharmaceutical products – a noteworthy exclusion. Yet, even these underestimates represent almost one in five of deaths from all causes. Drug-related deaths are a serious problem in Canada. However, the disturbing reality these numbers represent does not, and never did, justify the war on drugs. A sensible response to this level of carnage is not one of harassing, arresting, convicting and imprisoning drug users - essentially oppressing their rights, and in many cases, destroying their lives. But we should not dismiss the data or the concern about drug-related deaths simply because the data have been used to forge delinquent drug policy. The data have their own inherent legitimacy which needs to be repurposed as part of a drug policy strategy based, not upon fear or bigotry, or upon the desired trajectory of one’s political career, but upon principles of social justice and public health.

In the media and in prime time television shows, over many decades, we have been frequently exposed to gruesome deaths related to street drugs such as LSD, heroin, speed, cocaine, crack, and more recently crystal meth and bathsalts. Occasionally, a death from a drunk driver would appear. But the reality of drug-related mortality is quite different. The Canadian Centre on Substance Abuse’s Report, The Cost of Substance Abuse in Canada crafted an important marriage of data on drug mortality with the type of drug involved. In doing so, it provided one of the most important insights ever in the addiction field. It was a game-changer. This report identified tobacco as the major cause of drug-related mortality. Against the prominent backdrop of the war on drugs, that finding surprised a lot of people – even people working in the drug and health care fields. But the much greater surprise for just about everybody was the magnitude of the gulf between the number of tobacco-related deaths and those related to other drugs, including alcohol. Tobacco accounted for a staggering 86.7% of all drug-related deaths in Ontario. Alcohol came in at 9.1% and all illegal drugs combined at 4.2%.This picture is not different from the rest of Canada or from most places in the world.

The data from The Cost of Substance Abuse in Canada was collected in 2002. We have some more recent data from reports published by The Institute for Clinical Evaluative Sciences (ICES) & Public Health Ontario (PHO). These reports do not use the drug categories (“tobacco, alcohol & all illegal”). Using data collected from 2005-7, ICES/PHO show that deaths per year and years of life lost (YLL) are much higher for alcohol than for cocaine & for prescription opioids. This difference remained when YLLs were combined with year-equivalents of reduced functioning (YERF). Finally, using data from 2001-5, it was shown that life expectancy, adjusted for quality of life, was reduced for those who smoked tobacco at unhealthy levels compared to those who drank alcohol at unhealthy levels. So, based upon these more recent data sets, the general picture for mortality in 2002 appears unchanged. Tobacco is still the major threat, followed distantly by alcohol, and then by other drugs.

I would like to share an interesting perspective on the causative mechanism for tobacco-related mortality - a perspective that arises from epidemiology. Any contagion that causes disease is spread by a vector. A greater exposure of a vulnerable population to the vector results in a more widespread epidemic of the disease. For example, the parasitic contagion that causes the disease malaria is spread by the mosquito as the vector. The identification of the vector is always an important step in addressing the spread of a disease. For tobacco-related disease and mortality, the vector is the tobacco industry’s promotion and distribution of its product. The focus of attention on this vector is believed to have played a major role in reducing tobacco use. We need to learn from that success in addressing other drug problems. Those lessons will also serve our initiatives aimed at other lifestyle problems and issues such as unhealthy eating, compulsive gambling and gaming, and violent media.

This post brings us to the homestretch of our reconnaissance of indicators of drug-related harm. Over thirteen posts (plus one more to come), we have sorted through a lot of data, identified strengths and limitations of the data sources, discussed a variety of methodological issues, explored drug use within a broad societal context, told stories, made confessions, challenged  convention, courted controversy, and even worked in some Shakespearean and nautical metaphors. I would like to acknowledge the contributions to the discussions that some of you have made along the way. You enriched the experience for everyone, including for myself. In the final post of this series, I will briefly reintroduce and summarize the results of the six indicators and finally offer, for your consideration, an answer to the question that I posed 22 weeks earlier (May 19): What is the worst drug problem?

Dependency on a drug may not be a problem on its own, but it can be. First, let’s consider examples of when it is not typically a problem.

Caffeine is probably our most prevalent example of drug dependence. However, its habitual use tends to be non-problematic. I say this with all due respect to 18^th century English writer, Samuel Johnson who once referred to himself as “…a hardened and shameless tea drinker.” I think we can assume that Johnson’s statement was rendered more from wry wit than as confession. We should also acknowledge that CAMH’s OSDUHS has begun to monitor the use of high-caffeine energy drinks by students – a wise move I think, given research suggesting some potential for harm in young people from regular heavy doses of caffeine.

There are also examples in which dependence actually constitutes a viable and evidence-based harm reduction tactic. Consider nicotine as another very prevalent drug dependency. It is important to remember that it is not nicotine per se that is the most serious source of harm. (Although, it is not entirely benign either.) It is the constituents of the cigarette smoke that are most harmful. The nicotine gets you hooked – the smoke does the harm. E-cigarettes, while seemingly less harmful, are also not entirely benign. The point to which I am zig-zagging towards is that the person who uses any one of a variety of nicotine-delivery devices such as the patch, gum, inhalers, and the currently controversial e-cigarettes, is still drug dependent (upon nicotine) in every sense of the concept. But the use of these products is clearly preferred to inhaling smoke from the combustion of tobacco. Also consider that a person who uses methadone to avoid opioid withdrawal is still drug dependent (upon opioids). Methadone allows them to escape a lifestyle of illegal activities, high-risk drug use practices, undesirable associates, and exposure to contaminated, or otherwise unsafe, even deadly, contraband drug product. Methadone also makes it easier for the person to function productively and maintain a state of good health. Under safe circumstances, continued drug dependence can be a viable harm reduction intervention – a good thing.

But drug dependence can also seriously disrupt a person’s life. If circumstances such as a developing medical condition or a change in vocation or legal status that require abstinence were to arise, this could pose some difficulty for the person. Overcoming dependence, or a habit, can be a major challenge for some people, and some will require support to do so. Drug dependence can also divert a person’s time, attention, and resources away from other important aspects of life – financial, social, vocational, or family obligations. This aspect of dependence has been effectively captured in The World Health Organization’s definition: “…a cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance takes on a much higher priority for a given individual than other behaviours that once had greater value…”. It is this incursion of drug dependence into a person’s pre-existing priorities that can be harmful to the user and to those around him. This is also a major part of the reason why the low-risk alcohol drinking guidelines have a limit for weekly drinking that is lower than the daily limit multiplied by seven. The point is that risk is most effectively avoided by not drinking alcohol habitually – that is, every day. Some people would find that difficult. If you drink every day, try going a couple days each week without and see how much of a challenge it is. It just might be an interesting learning experience. (Remember to monitor those seemingly justifiable excuses!)

So just how prevalent is drug dependence, and on which drugs are Ontarians most likely to be dependent?

An interesting passage in CAMH’s Cannabis Policy Framework (page 4) alludes to research concerning probabilities of developing dependence from the use of various drugs. The probability is highest for nicotine at 68%, followed distantly by alcohol at 23% and cocaine at 21% (all considerably higher than that for cannabis at 9%). The prominence of nicotine reflects something that I have referred to previously – that the modern day cigarette is strategically designed as an optimum nicotine delivery device to create dependence as quickly as possible and maintain that dependence in the face of quit attempts. That’s how the tobacco industry maximizes per customer revenue before the  customer dies from using the product.

We can examine the actual prevalence of dependence in the general population through the CAMH Monitor which uses the Alcohol Use Disorders Identification Test (AUDIT), the Heaviness of Smoking Index (HSI), and the Alcohol, Smoking & Substance Involvement Screening Test (ASSIST) to assess prevalence of dependence in the general population for alcohol, tobacco, and cannabis respectively. The data show that 6.6% of Ontario adults are dependent upon alcohol while 6.5% are dependent upon tobacco. The most recent survey was unable to provide a reliable estimate for cannabis, but a previous edition of the Monitor provided an estimate of 1%. It is likely that the current prevalence of dependence on cannabis (or any other drug) remains well below that of tobacco and alcohol.

So prevalence of dependence is essentially equal for alcohol and tobacco among Ontario adults. In my next post on the sixth (and final) indicator for determining the worst drug problem, we will explore the data on drug-related deaths.

Before anyone gets too excited, I should tell you that my history of drug dependence will never make it onto the cover pages of the magazines at the checkout counters at the grocery store. This is for two reasons. One is that my history is relatively mediocre by Hollywood standards. The other is that the magazines don’t care about drug dependence in a non-celebrity, and neither does their regular audience.

When I am talking to a class of students about drug problems I sometimes challenge the regular coffee/energy drink users to go a week without - just to obtain a small taste of what breaking a drug habit is like. Drawing upon the well-established known effects and upon my own experience, I remind them that they will feel lethargic for a few days and may experience headaches - quite benign as withdrawal syndromes go. But that’s not the important lesson. What’s important to learn is how easy it is, during the week, to come up with reasons why one should break the vow of abstinence and have a coffee or energy drink. I have to pull an all-nighter to finish this assignment. I have to stay awake in class. I have to drive a long distance. My friends will think I am weird. None of these are really compelling reasons. There are almost always workarounds available. But while in the throes of caffeine withdrawal, these excuses take on surface-level legitimacy in their service of academic performance, personal safety, and peer acceptance. I find the same dynamic comes into play when I have tried to change my eating habits or stay on a regular exercise regimen. It is very easy to give in on a single occasion for what we are convinced is a justifiable and forgivable reason at the time. Before we know it, the isolated single exceptions have begun to add up and gradually morph back into the customary pattern. This experience provides an important insight into a small part of the struggle of someone with a serious drug dependency.

I recall one of my many attempts to quit smoking as an undergraduate. (There’s an old joke: ‘quitting smoking is easy – I’ve done it lots of times’.) In those days at the University of Waterloo, we were actually allowed to smoke in class. Many of the desks had one of those flimsy tinfoil ash trays, always part-filled with a layer of ash and several butts. Some students would occasionally roll their own tobacco cigarettes but with a little extra something - just to make a boring drug like nicotine more interesting.  When the university brought in the smoke-free policy it posed a major disruption in the lives of smokers and was widely ignored by students and faculty alike. I had a political science professor who chain-smoked as he paced and lectured, lighting his next cigarette with the current one before extinguishing it. He was neither a champion nor an early adopter of the new policy. To make things interesting, some of the pink-lunged fanatics behind the new policy took exception to the continued smoking in the classrooms. Add in a few people in a highly impatient and easily-irritated state of nicotine withdrawal, and things became even more interesting. In one class, harsh words were exchanged between a pro- and an anti- which quickly escalated into a physical brawl, the antagonists rolling about on the floor, exchanging blows, and dislodging desks and the hapless students who were sitting in them. It is difficult to imagine such a scene on today’s campuses – a powerful testimony that social norms can dramatically change –painfully slowly perhaps - but they do change. What seems impossible in the short-term can be inevitable in the long-term.

Well before the non-smoking policy was enacted at Waterloo, I had been trying to quit and without much success. I tried a harm reduction approach of reducing the number of cigarettes I smoked per class. While this was somewhat successful, it came at a cost. I was directing so much of my attention to clock-watching (to get my next nicotine dose) I was missing some of the lecture content. There were no online backups in those days. If you missed it in the lecture, you missed it. You could always prevail upon a classmate’s generosity to lend you notes, but after a while you become a nuisance, especially if your classmate was an unsympathetic non-smoker. So my dependence on nicotine was actually interfering with my learning. This realization provided the motivational fuel for what would become my most successful quit attempt yet (but still not my last). Ultimately, I did it cold-turkey, but not without visiting some misery on those people closest to me. Nicotine replacement products were not so readily available in those days.

My other disclosure comes from a time when I lived in a student residence where there would occasionally be an extended drought of cannabis product. During such droughts there was a noticeable change in people’s mood and tolerance of others. Non-users learned to tread carefully in all matters of residence decorum. I had good friends in both camps, and occasionally was called upon as peace-keeper. This was not an easy assignment given my own adventures which swirled somewhat out of control in the first semester of that year - during which I earned the worst marks in my academic history. This prompted a bit of soul-searching over the holiday break during which I reacquainted myself with my longer-term life objectives. The second semester saw the best academic performance of my life. I emerged all the wiser and fortunately with relatively little harm incurred.

These days, I maintain a hardened and shameless dependence on dark chocolate.

In my next post, we will take a less narrative and more academic approach to drug dependence - looking at definitions and data. We will also log another entry in our epic journey to unveil the worst drug problem.

Drug-related Harm in the General Population: It’s Huge

In previous posts I have sung the praises of CAMH’s Ontario Student Drug Use and Health Survey (OSDUHS) and the CAMH Monitor which provide highly useful survey data on drug use, experiences, opinions and related problems. This gives us an important source of information about the impact of drugs in the general population. We have drawn on these surveys repeatedly in pursuit of identifying the worst drug problem, and will do so in this post, concentrating on indicators of drug-related harm from the 2013 editions.

First, it is important to cover some foundational and definitional matters. A limitation is one common to all general population surveys. Because of limited sample size, they are not able to provide reliable estimates of related problems for drugs with low prevalence of use in the general population – which is the case for most illegal drugs. For any drug with low prevalence of use, the prevalence of related problems will be correspondingly lower. This produces unreliable population estimates, which are rightfully suppressed from publication.  So we have data on related problems for only those drug types with higher prevalence of use – notably alcohol and cannabis.

The surveys use psychometrically-validated instruments for assessing harm related to alcohol and cannabis use. These include The Alcohol Use Disorders Identification Test (AUDIT) and the Cannabis Involvement Scale of the WHO’s Alcohol, Smoking & Substance Involvement Screening Test (ASSIST 3.0).  These instruments cover drug-related harm to personal well-being or functioning, social responsibilities and relationships, and acute physical harm. Specific harms include: being unable to remember events of an episode, feeling guilt or remorse as a result of something that happened, having failed to do something that one was supposed to have done, having been advised to reduce use, and having injured oneself or others.  Given the focus on acute harm, these indicators work well for alcohol and various other types of drugs. They do not work well for tobacco given that harm related to its use tends to involve chronic disease and premature mortality rather than acute harm. 

So, what is the picture that emerges? In the CAMH Monitor, the AUDIT shows that 13.7% of adults reported harm from their use of alcohol in the previous twelve months. The ASSIST shows that 7.5% of adults reported harm from their use of cannabis in the previous three months. The differing time frames provide an important caveat for any temptation to compare these two prevalence figures. If cannabis problems were likewise reported within a twelve-month time frame, the figure would probably increase and be closer to that reported for alcohol.

For adolescents (students), the OSDUHS provides data on problems related to alcohol, and on problems related to any drug other than alcohol. The AUDIT is used for alcohol and the CRAAFT Screener for other drugs. Combining all drugs other than alcohol in the CRAAFT increases the captured prevalence such that limited sample size for individual drugs is not a problem. Of students in grades 7-12, 15.7% scored high enough on the AUDIT to indicate harmful drinking. Among grade 9-12 students 16.8% scored sufficiently high on the CRAAFT Screener to indicate a level of harm to warrant treatment. Note the difference in which grades were included in the two indicators. If  CRAAFT Screener data were reported for the lower grade students, as was alcohol, the prevalence percentage would likely drop to one that was lower than that obtained for alcohol with the AUDIT. It is probably safe to conclude that alcohol use is problematic for at least as many students as are all other drugs combined.

So, to summarize, between seven and seventeen percent of people in the general population use alcohol or cannabis in ways that cause them harm. That is substantial.  And where does this bring us in our quest to identify the worst drug problem ? To summarize the picture for drug-related harm from this and the previous post, tobacco was prominent in hospital care, but alcohol was prominent in specialized addiction treatment programs, crime statistics, and population surveys. I think we once again have to give the nod to alcohol. But as with the Toronto Blue Jays, it would be premature to declare victory just yet. Two indicators remain – dependence and mortality – where some surprises may lurk. See the next post in two weeks when I return from some field work in the Loire Valley and Bordeaux wine regions.